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Clin Med I Exam #2 > L4: Allergic Rhinitis, Tinnitus, and Urticaria > Flashcards

L4: Allergic Rhinitis, Tinnitus, and Urticaria Flashcards

1
Q

Define barotrauma.

A

Discomfort or damage due to pressure differences between the MIDDLE EAR and the outside world.

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2
Q

List 2 common causes of barotrauma.

A

Flying

Diving

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3
Q

List common sx associated with barotrauma.

A

pressure, pain, hearing loss, or tinnitus

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4
Q

What are common PE findings associated with barotrauma?

A
  • Middle ear effusion
  • Hemotympanum (blood in middle ear)
  • Possible TM rupture
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5
Q

True or false: barotrauma typically heals on its own over time.

A

True

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6
Q

List the tx for barotrauma

A
  • AVOIDANCE
  • Oral or nasal decongestants
  • Swallowing, valsalva, chewing gum, etc.
  • Goal is to equalize middle ear pressure
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7
Q

Under what circumstance would you refer barotrauma to ENT?

A

If perilymphatic fistula present (vertigo and sensorineural hearing loss)

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8
Q

What kind of tumor is an acoustic neuroma?

A

Schwann cell tumor

*SLOW growing!

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9
Q

Where do acoustic neuromas derive from?

A

Vestibular portion of CN VIII

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10
Q

What is another name for an acoustic neuroma?

A

Vestibular Schwannoma

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11
Q

What is a classical presentation for acoustic neuroma?

A

Unilateral sensorineural hearing loss and tinnitus

+/- gait disctrubance or other CN nerve involvement

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12
Q

How do you dx an acoustic neuroma?

A
  • Audiometry is best initial test
  • Followed by MRI
  • Important to r/o meningioma
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13
Q

Tx for acoustic neuroma?

A
  • Surgery
  • Radiation
  • Observation
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14
Q

Define tinnitus

A

Perception of sound in one or both ears (buzzing, ringing, pulsatile, nonpulsatile)

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15
Q

What is tinnitus often an early indicator for?

A

Cochlear hair cell dysfunction or loss

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16
Q

What type of tinnitus is most commonly vascular in etiology?

A

Pulsatile (best to refer to ENT)

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17
Q

List some possible causes of tinnitus (6)

A
  1. Ototoxic meds (ex: aminoglycosides)
  2. Presbycusis (SN hearing loss w/ aging)
  3. Otosclerosis (fusion of ear bones)
  4. Vestibular Schwannoma
  5. Chiari malformations (issue with cerebellar tonsils or something)
  6. Barotrauma
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18
Q

How do you dx tinnitus

A
  • Hx
  • PE (complete head and neck exam, auscultate for bruitis in pts with possible vascular tinnitus)
  • Refer to ENT if pulsatile
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19
Q

What is a common symptom associated with tinnitus you should be concerned about?

A

Anxiety and depression

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20
Q

What is the tx for tinnitus?

A
  • MAIN GOAL IS TO LESSEN AWARENESS ON IMPACT AND QUALITY OF LIFE
  • Behavioral therapy
  • Benzodiazepines (Xanax)
  • White noise masking devices
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21
Q

Define seasonal allergic rhinitis

A
  • AKA “hay fever”

- Occurs at particular times of the year (trees, grass, ragweed)

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22
Q

Define perennial allergic rhinitis

A
  • Occur year round

- Dust mites, cockroaches (ew), mold, animal dander

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23
Q

How do you differentiate between allergic rhinitis vs. vasomotor rhinitis

A

Allergic rhinitis will experience episodes of sneezing, rhinorhea, and nasal obstruction (often accompanied by itchy eyes, nose, and palate)

Vasomotor rhinitis is non-allergic (AKA perennial non-allergic)

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24
Q

What is the typical age of onset for allergic rhinitis?

A

< 30 years old (peak incidence in childhood/adolescence)

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25
Q

What does allergen exposure produce in regards to allergic rhinitis?

A

IgE antibodies

  • These sensitize mast cells and basophils
  • These cells then degrade and release inflammatory mediators (histamines)
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26
Q

List the 3 primary sx of allergic rhinitis (AR).

A
  1. Rhinorrhea (runny nose)
  2. Sneezing
  3. Nasal congestion
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27
Q

What is a v important risk factor for allergic rhinitis you should def know?

A

FAMILY HX OF ATOPY!!! Remember the atopic triad.

There’s others. But like know this one. (L4 slide 22)

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28
Q

List the 5 primary areas you should assess during a physical exam for allergic rhinitis

A
  1. Periorbital area
  2. Eyes (sx usually bilateral)
  3. Nose
  4. Throat
  5. Ears
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29
Q

What are the 2 common findings in the periorbital area associated with AR?

A
  1. ALLERGIC SHINERS: bluish purple rings around both eyes
  2. DENNIE-MORGAN LINES: skin folds under eyes consistent with allergic conjunctivitis

Big letters = buzz words ;-)

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30
Q

What PE findings might you find in the eyes for a pt with AR?

A
  • Diffuse redness involving the bulbar and palpebral conjunctiva
  • Tearing or clear watery discharge
  • Chemosis (swelling)
  • Eyelid edema
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31
Q

What PE findings might you find in the nose for a pt with AR?

A
  • PALE, BOGGY, “BLUISH” MUCOSA *Buzz words baby!!!
  • Clear discharge
  • Nasal crease secondary to “allergic salute”
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32
Q

What PE findings might you find in the throat for a pt with AR?

A
  • Post nasal drainage in posterior pharynx

- “Cobblestoning” (swollen LN tissue)

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33
Q

What PE findings might you find in the ears for a pt with AR?

A

Retracted TMs and/or serious otitis media (OME)

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34
Q

How do you diagnose AR?

A
  • Clinical dx

- Allergy testing can be confirmatory but not necessary for initial dx

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35
Q

What are the 2 types of allergy testing that can be ordered?

A

Skin testing: scratch or prick skin testing

Serum testing: ImmunoCAP

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36
Q

What indicates a positive scratch (prick) test?

A

“wheal and flare” rxn with wheal size > or = to histamine control of 3mm

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37
Q

Which of the 2 allergy skin tests puts the patient at greatest risk for anaphylaxis?

A

Scratch test

Serum testing is less risk, but also less sensitive and more expensive

38
Q

What is the general tx for AR?

A
  1. Avoidance of allergens
  2. Pharmacotherapy
  3. Immunotherapy
39
Q

What are the pharmacotherapy options for AR?

A
  • Oral or intranasal antihistamines
  • INTRANASAL GLUCOCORTICOSTEROIDS!
  • Sympathomimetics/decongestants
  • Leukotriene receptor antagonists
40
Q

What do 1st generation antihistamines help to alleviate in regards to AR? What do they not help with?

A

Help w/ sneezing, rhinorrhea, and itching

No help w/ nasal congestion

41
Q

List two 1st generation antihistamines

A

-Chlorpheniramine (Chlor-trimeton)
-Diphenhydramine (Benadryl)
KNOW THESE NAMES PEOPLE. YOU CAN DO IT!

42
Q

What are the side effects of 1st generation antihistamines?

A

SEDATION, dry mouth, constipation

43
Q

What is a benefit of 2nd generation antihistamines?

A

LESS SEDATING, but no more effective otherwise

44
Q

Name 3 2nd generation antihistamines.

A
  • Loratadine (Claritin) QD
  • Fexofedadine (Allegra) QD or BID
  • Cetrizine (Zyrtec) QD
45
Q

What is the mode of action for an antihistamine nasal spray?

A

H1 antagonist

46
Q

List a benefit and side effect of antihistamine nasal spray

A

Benefit: Rapid onset; dose BID
Disadvantage: Tastes gross and bitter

*May be used alone or in combo with steroid nasal spray

47
Q

What is the mode of action for cromolyn nasal spray?

A

Mast cell stabilizer

48
Q

What is a disadvantage of cromolyn nasal spray?

A

Lower efficacy; needs frequent dosing

49
Q

What is the LEAST RISKIEST med you can prescribe for a pt with allergic rhinitis?

A

Cromolyn nasal spray; no serious side effects :-)

50
Q

Are oral antihistamines or nasal steroid sprays more effective?

A

Nasal steroid sprays

1st and 2nd generations available; lower bioavailability with second generation

51
Q

What is a side effect of nasal steroid spray use?

A

Epistaxis (tell pt to point away from nasal septum)

52
Q

How can leukotriene receptor antagonists (like Singulair) be used most efficiently for AR?

A
  • LTRA are less effective than nasal steroid sprays

- LTRA + 2nd gen oral antihistamine provides more relief than either alone (synergism!)

53
Q

What is other name for sympathomimetics?

A

Decongestants

54
Q

When would you recommend a sympathomimetic (decongestant)?

A

If the pt has marked congestion despite antihistamine use. VASOCONSTRICTION will decrease edema and secretions

55
Q

Name a sympathomimetic

A

Sudafed

Be careful; crazy ppl make meth with this lol

56
Q

Patients with what medical conditions should you be cautious about prescribing a sympathomimetic (decongestant)?

A
  • Hypertension

- Cardiac disease

57
Q

Describe immunotherapy (what is it effective for, how is it given, how long does the tx take)

A
  • Effective for tx of ALLERGIC conjunctivitis, rhinitis, and asthma
  • Gradual administration of increasing amounts of allergen
  • Can be given in subcutaneous or sublingual forms
  • Requires multiple, regularly scheduled visits over a period of 3-5 years
58
Q

What tx would you recommend for a patient <2 years old with AR?

A
  • Cromolyn sodium nasal spray

- 2nd gen antihistamines (Cerizine (Zyrtec) approved for children > or = to 6 months)

59
Q

What types of treatments would you recommend for a patient > 2 years old with MILD allergic rhinitis? (4 options)

A
  • 2nd generation oral antihistamines (Claritin, Zyrtec, Allegra)
  • Antihistamine nasal sprays (Azelastine, Olopatadine)
  • Glucocorticoid nasal sprays (use for continuous or episodic AR 2-3 days prior to exposure)
  • Cromolyn nasal spray (least effective)
60
Q

What is the first line of treatment for a patient with MODERATE TO SEVERE allergic rhinitis? Why?

A

Glucocorticoid nasal sprays

  • Most effective single agent
  • Few side effects
  • Many options (newer meds more convenient and safer for long term use)
61
Q

Name the glucocorticoid nasal sprays recommended for children > or = to 2 years of age? (2)

A
  1. Mometasone (Nasonex)

2. Fluticasone furoate (Veramyst)

62
Q

Name the glucocorticoid nasal spray recommended for children > or = to 4 years of age?

A

Fluticasone proportionate

63
Q

Aside from glucocorticoid nasal sprays, what other treatments would you use for AR?

A

(these can be used as a second agent w/ the steroid nasal sprays)

  • Antihistamine nasal spray
  • Oral antihistamine
  • Cromolyn nasal spray
  • Montelukast (Singulair)
  • Oral antihistamine/decongestant combo
64
Q

What tx would you use for a pt with AR with concomitant asthma?

A

Montelukast (Singulair): provides useful additive therapy

65
Q

What tx would you use for a pt with AR and allergic conjunctivitis? What 2 conditions should you avoid using this combo in?

A

-Steroid nasal spray + ophthalmic antihistamine drops

CAUTION: Avoid nasal steroid sprays in pts with glaucoma or cataracts!

66
Q

When would you refer a pt with AR?

A
  • If severe or refractory sx
  • If AR and asthma; consider pulmonologist
  • If recurrent sinusitis or otitis media; refer to ENT
67
Q

What is another name for non-allergic rhinitis?

A

Vasomotor rhinitis

Also called perinneal non-allergic rhinitis

68
Q

What is non-allergic rhinitis? What are the triggers?

A
  • ABNORMAL AUTONOMIC RESPONSE

- Triggered by stress, sexual arousal (lol what?), perfumes, cigarette smoke, temperature changes

69
Q

What are the primary sx of non-allergic rhinitis? What are the pertinent negatives that differentiate it from AR?

A

Primary sx:

  • Nasal congestion
  • Rhinorrhea
  • and/or post nasal drip

Pertinent negatives:
-NO ocular/nasal itching or sneezing

70
Q

What is the primary tx for vasomotor (non-allergic) rhinitis?

A
  • Avoidance of triggers
  • Nasal steroid sprays
  • Antihistamine nasal sprays
  • IPRATROPIUM NASAL SPRAY (anticholinergic)
    • Use this if rhinorrhea is the prominent sx!
71
Q

What specific tx would you recommend for a pt with vasomotor rhinitis whose primary complaint is rhinorrhea?

A

Ipratropium nasal spray (anticholinergic)

72
Q

How would you describe a nasal polyp?

A

-Pedunculated (elongated stalk of tissue), non-tender, gray soft tissue growths

73
Q

What is the primary sx of a nasal polyp?

A

Nasal congestion/obstruction

74
Q

What condition’s might cause the presence of a nasal polyp?

A
  • Allergic rhinitis
  • Vasomotor rhinitis
  • Chronic sinusitis
  • Asthma (“Samter’s Triad”)
75
Q

What is the tx for a nasal polyp?

A

Nasal steroid spray

Refer to ENT for obstructive sxs

76
Q

What is the cause of rhinitis medicamentosa?

A
  • Regular use of a decongestant nasal spray (ex: Afrin)
  • > 3 days of use leads to rebound congestion (pts will increase frequency of use to obtain temporary relief; leads to dependency)
77
Q

What would you see on PE w/ a patient who has rhinitis medicamentosa?

A

Erythematous and swollen mucous membranes

78
Q

What is the tx for rhinitis medicamentosa?

A
  • Discontinue Afrin

- Start steroid nasal spray

79
Q

How would you describe urticaria (hives)?

A

Well circumscribed, intensely PRURITIC, raised wheals; PALE TO BRIGHT ERYTHEMA
+/- central pallor

80
Q

What is the time length for acute urticaria?

A

present less than 6 weeks

81
Q

What is the time length for chronic urticaria?

A

s/s recurring most days of the week for 6 weeks or longer

82
Q

How long does an individual urticaria lesion last?

A

Disappear within 24 hours

Lesions are TRANSIENT

83
Q

What is the cause of urticaria?

A
  • Release of histamines from cutaneous MAST CELLS of superficial epidermis
  • Can be accompanied by angioedema
84
Q

What are some common causes of urticaria?

A
  • Infections
  • Allergic rxn to meds
  • Foods (milk, eggs, shellfish, etc.)
  • Insect/bee stings
  • Direct mast cell activation (morphine, codeine, etc.)
  • NSAIDs
85
Q

How do you dx urticaria?

A

-Clinical dx based on H&PE (past hx of hives, signs and sx of anaphylaxis, new foods or meds, insect bite, etc.)

86
Q

What is urticaria easily confused for? What are the sx?

A

Urticarial vasculitis:

  • Fixed (lasting longer than 24 hours) erythematous, painful, urticarial plaques with blanching halos
  • Leaves residual hyperpigmentation or purpura
  • Linked with SLE
87
Q

What is the tx for urticria

A

-H1 HISTAMINE BLOCKER (2nd generation) are the preferred first line-therapy

Can also use:

  • H2 histamine blocker in combo with H1
    • Ranitidine (Zantac), famotidine (Pepcid), Cimetiidine (Tagament)
  • Use oral glucocorticoids if angioedema or persistent sx
88
Q

Why do we prefer 2nd generation H1 histamine blockers?

A
  • Minimal sedation
  • No anticholinergic effects
  • Few drug-drug interactions
  • Less frequent dosing
89
Q

Name 2 H1 histamine blockers

A

-Certizine (Zyrtec)
-Levocetirizine (Xyzal)
These 2 may be more affected due to mast cell-stabilizing properties

90
Q

Who is the Assistant to the Regional Manager?

A

Dwight K. Schrute YOU IDIOT

Clin Med I Exam #2 (6 decks)

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